Evaluation of Bhagat Puran Singh Sehat Bima Yojana in Punjab

Home , Bhagat Puran Singh

EVALUATION OF BHAGAT

PURAN SINGH SEHAT BIMA YOJANA IN PUNJAB

2018

SHAIK IFTIKHAR AHMED

POPULATION RESEARCH CENTRE CENTRE FOR RESEARCH IN RURAL AND INDUSTRIAL DEVELOPMENT (CRRID) 2A, SECTOR 19A, CHANDIGARH

CONTENTS

List of Tables ii

List of Figures ii

List of Abbreviations iii

Acknowledgements iv

Page No

Introduction 1

Aim and Objectives 2

Review of Literature 2

Methodology 6

Status of BPSSBY 6

Background Characteri stics of BPSSBY Card Holders 9

Housing Characteristics of BPSSBY cards holders 12

Enrolment in BPSSBY 14

Level of Awareness 17

Utilization of BPSSBY 21

Satisfaction among beneficiaries 25

Concluding Remarks with Recommendations 26

References 29

List of Tables

Table No Title Page No. 1 District wise Number of Households Enrolled for BPSSBY, 2018 7 2 BPSSBY District wise Claims Status (November 2016 to July 2018 ) 8 3 Age, Gender, Marital Status and Caste Characteristics of the 10 BPSSBY Card Holders 4 Educational and Occupational Status of the BPSSBY Card Holders 11 5 Housing Characteristics of BPSSBY Card Holders 13 6 Source of Information for Enrolment in BPSSBY 14 7 Year of Enrolment for BPSSBY and Time taken to get BPSSBY Card 15 8 Enro lment Fee Paid for BPSSBY 16 9 Documents Submitted for the Enrolment Process 16 10 Aware ness about all the Benefits of the BPSSBY 17 11 Awareness about BPSSBY with respect to Educational Qualification, 18 Caste and Occupation 12 Awareness about Monetar y Benefits Available under BPSSBY 19 13 Awareness about the Cashless Treatment under BPSSBY 19 14 Awareness on Major Components of BPSSBY 20 15 Awareness on the Amount Deducted at Discharge 21 16 Ailments Treated under BPSSBY 21 17 Scheme Availed for Surgeries 22 18 Preference for the Type of Hospital to Avail BPSSBY for Surgeries 22 19 Reasons for Choosing Health Facilities for Treatment 23 20 Health Facility wise Distribution of Reasons for Choice of BPSSBY 23 Beneficiaries on Place of Treatment 21 Beneficiaries Experience on Out of Pocket Expenditure during 24 Treatment

List of Figures

Fig. No Title Page No. 1 Age of the Beneficiaries 9 2 Family Income of the Card Holders 12 3 All kind of medical treatment and tests are covered under 24 BPSSBY: Beneficiaries perception

List of Abbreviations

ACCORD Action for Community Organisation Rehabilitation and Development APL Above Poverty Line BC Backward Class BCH Blue Card Holder BPL Below poverty line BPSSBY Bhagat Puran Singh Sehat Bima Yojana CBHIS Community Based Health Insurance Schemes CES Consumer Expenditure Survey CH Civil Hospital CHIS Community Health Insurance Schemes ENT Ear, Nose and Throat GOI Government of India KKVS Kadamalai Kalanjam Vattara Sangam MOSPI Ministry of Statistics and Programme Implementation NFHS National Family Health Survey NSSO National Sample Survey office OOPE Out Of Pocket Expenditure RSBY Rashtriya Swasthya Bima Yojana SC Scheduled Caste SMS Short Message Service ST Scheduled Tribe UTI Urinary Tract Infection

iii

Acknowledgements

I am highly grateful to the Dr. Rashpal Malhotra, Executive vice Chairman, Centre for Research in Rural and Industrial Development (CRRID) Chandigarh, for providing consistent guidance, support and encouragement for completing this study. Thanks are due to Shri Sunil Bansal, Director General (acting), CRRID for his guidance at different stages of the study.

I am grateful to the officials of State Nodal Angency, Bhagat Puran Singh Sehat Bima Yojna, Punjab Health System Corporation, SAS Nagar, Mohali for the support provided by them during the field survey. I am also grateful to my colleagues Dr Neetu Gaur and Dr Gurinder Kaur for their unfailing support.

Shaik Iftikhar Ahmed Research Assistant Population Research Centre Centre for Research in Rural and Industrial Development Chandigarh

EVALUATION OF BHAGAT PURAN SINGH SEHAT BIMA YOJANA IN PUNJAB

INTRODUCTION India is a second populous country in the world and also the largest democracy. Since independence, considerable progress has been made in terms of the health indicators and health infrastructure. However, healthcare costs in India are not only high but also rising. The rise in health care demand has increased the cost of health care services to the extent that specialized care is beyond the reach of many people. The expenditure on health care can push families into financial distress.

Inpatients in India spend on an average 58% of their total annual expenditure on hospitalisation. Over 40% of hospitalized Indians borrow heavily or sell assets to cover their medical expenses. Over 25% of hospitalized Indians get pushed below poverty line because of hospital expenses (Pandve 2012). High out-of-pocket health expenditure is a major barrier to access for healthcare. Health insurance could be an option to cope up with the rising healthcare costs. To address this issue, in 2008 Government of India introduced the “Rashtriya Swasthya Bima Yojana” or National Health Insurance Programme (RSBY). RSBY is uniquely mandated to cover the entire territory of India and all occupational groups. Eligibility for RSBY coverage applies to all the BPL population and entails full premium subsidy, and the GOI extended the same terms to certain “above poverty line” (APL) groups.

In Punjab, RSBY was launched on 19 July, 2008. At state level, the scheme is being implemented through State Nodal Agencies. Smart card based health insurance cover of Rs. 30,000/- per family (a unit of five) per annum on a family floater basis is being provided under the scheme.

In an agricultural dominated state such as Punjab; health schemes are crucial for the benefits of farmers and agricultural labourer. Due to present agrarian crisis in Punjab, 449 farmers committed suicide in 2015 (March 01, 2016, HT). In this situation of crisis, schemes like “Bhagat Puran Singh Sehat Bima Yojana” can be a healing touch for the downtrodden families of Punjab. The health department of government of Punjab has launched a cashless health insurance scheme named “Bhagat Puran Singh Sehat Bima

Yojana” in 2015 for Blue Card Holder (BCH) families. This scheme covers 28.5 lakh Blue Card Holder families who will get the benefits of cashless treatment in 214 government and 216 private hospitals in the state. The scheme provides insurance covers households having Blue Card, J-form holding farmers, traders and even construction workers. This scheme provides cashless medical treatment of up to Rs 50,000/- every year. The main benefit of this scheme is that it provides cashless facility to beneficiaries. The main objective of the scheme is to provide financial protection to weaker section of the society by reducing their expenditures regarding health. In this scheme there is also the provision of the benefit of Rs 5 lakh per head of family in case of accidental death and permanent disabilities. This scheme also incorporates one day pre hospitalization and five days post hospitalization benefits respectively.

The success of any policy or scheme is mainly dependent on how efficiently it is implemented, monitored, evaluated and improved/terminated. If this efficiency criterion is satisfied then surely this scheme will prove beneficial for lower or weaker section of the society.

BPSSBY is the cashless medical health insurance scheme launched under one of the flagship programme of the State with an objective to provide protection to economically weaker households from financial liabilities arising out of health shocks that involves hospitalization.

AIM AND OBJECTIVE The main aim of present study is to evaluate the functioning and implementation of the Bhagat Puran Singh Sehat Bima Yojana in Punjab and to understand the beneficiary’s perspective about the scheme. Apart from this, issues raised by the health staff regarding the health insurance scheme are also highlighted.

REVIEW OF LITERATURE Life insurance business in India was initiated in 1818 with the establishment of the Oriental Life Insurance Company in Calcutta, which was further failed in 1834. Before independence, in 1870 the British Insurance Act was enacted and in the last three decades of 19 th century, the Bombay Mutual (1871), Oriental (1874) and Empire of

India (1897) were started in the Bombay presidency. The Indian life Insurance Act, 1912 was the first statutory measure to regulate life business. Various insurance companies were nationalised by the government (Nagaraju Y, 2014).

In order to make insurance schemes credible, government intervention is required and for this purpose various public health insurance schemes are introduced by the government. A number of studies have been conducted to evaluate the impact of public and private health insurance schemes and community based health insurance schemes (CBHIS).

Chatterjee Keya and Sinha Rajesh, (2014), examined the impact of India’s National Health Insurance Scheme in terms of health care utilisation pattern using National Sample Survey office (NSSO) consumer expenditure survey (CES) data of the year 2007- 08 of Ministry of Statistics and Programme Implementation, MOSPI, Government of India. They analysed that even after 3 to 5 years of implementation of this scheme, in terms of utilisation of hospitalisation services the benefits were yet to reach the resource poor households. They also showed that the expenditure for outpatient treatment contribute a higher share in overall health expenditure.

Rao Mala et al (2010) revealed that SCs and STs beneficiaries were significantly lower than their proportions in population in Rajiv Aarogyasri Community Health Insurance Scheme in Andhra Pradesh, India. The satisfaction survey of the beneficiaries showed the highest scores for doctors, nurses and cleanliness and the lowest score were for health camps and availability of information regarding this scheme.

Aggarwal Aradhna evaluated the impact of Yeshasvini Community based health insurance scheme on utilisation of health care, the intensity of use and financial protection among women. This study revealed that this scheme had a significant impact among women. However this scheme was not effective in increasing primary health care utilisation among them. This scheme has led to change the preference of insured household in favour of better health care services for the treatment of women and has offered significant financial protection to them. This showed that community insurance

3 presents a workable model for providing high end services in resource poor settings through an emphasis on accountability and local management.

Criel Bart et al (2008) conducted observational study in order to measure the patients’ (insured and uninsured) level of satisfaction in two CHI Schemes: Action for Community Organisation Rehabilitation and Development (ACCORD) and Kadamalai Kalanjam Vattara Sangam (KKVS). This study found that there is the same level of satisfaction between insured and uninsured patients because satisfaction was observed for the availability of doctors, medicines and recovery by the patient. The authors suggested that the scheme managers should negotiate actively for better quality of care with empanelled providers in order to improve the quality of care by the CHI schemes.

Dror M. David et al (2015) investigated the impact of CBHI in rural Uttar Pradesh and Bihar states of India on insured households’ self - medication and financial position. For non-hospitalisation events some insured households reported borrowing. The realised benefits of insurance included better access to healthcare reduced financial risks and improved economic mobility which suggested that health insurance creates welfare gains.

Selvary Sakthivel and K. Anup (2012) conclusively demonstrated that there is an increase in per capita healthcare expenditure particularly on hospitalisation by poorer section of the society who were enrolled in RSBY, Rajiv Aarogyasri of Andhra Pradesh and Tamil Nadu Health Insurance Schemes that is RSBY and other state government based interventions failed to provide financial risk protection. The authors suggested that policies should follow the universal approach of coverage.

Kuruvilla Sarosh and Liu Mingwei (2007) conducted case study of an important innovation in providing health care for the rural poor i.e. the Yashasvini Health Insurance Scheme for rural farmers and peasants in Karnataka, India. They discussed the obstacles in providing health insurance to the rural poor and informal sectors. These are stated as diversified nature of rural and informal sector’s population makes it difficult to organise them; geographical dispersion of rural and informal sector

4 population; no employers and rural and unorganised workers need employment, income and social security, so they are less interested in these schemes.

Nagaraju Y. (2014) studied the performan ce of health insurance schemes in India and conducted correlation analysis to find out the relationship between the awareness and type of the scheme, family coverage and receipt of smart card. The author found positive and significant correlation between awareness about the total sum assured, coverage to family, inclusion procedures, eligibility conditions and the type of scheme, but there is no significant correlation between the type of scheme and awareness about the period, sum assured at credit, empanelled hospitals and follow up procedures covered. There is no significant relation between number of family members covered and awareness, but receipts of biometric cards along with the information bulletin has positively and significantly correlated with awareness. The author suggested that government should not only implement these schemes but should also to ensure the proper working of these schemes.

Nandi Arindam et al (2014) reviewed the existing evidence on RSBY’s impact in the context of international literature on health insurance. The authors found that all studies related to impact of RSBY on healthcare utilisation are based on observational data which generate methodological challenges in understanding the true impact of RSBY. In order to remove these limitations micro level evidences should be used. Budget inconsistencies should also be addressed.

Prinja et al (2017) reported the impact of publicly financed health insurance schemes on health service utilization, out-of-pocket (OOP) expenditure, financial risk protection and health status. Based on various studies, they showed a positive effect in terms of increase in the consumption of health services with introduction of health insurance. However, there is no clear evidence yet to suggest that these have resulted in reduced OOP expenditures or higher financial risk protection.

It can be concluded from above mentioned studies that, in India many public health insurance schemes have been launched by the government but they are inefficient to allocate its benefits to all sections of the society. Among various constraints, diversified

5 geographical area and population and poor infrastructure are few main reasons highlighted for poor implementation of the schemes. In order to strengthen these schemes, an evaluation of these schemes may help bring out areas of intervention that may help to bridge the gaps in the execution of health schemes. The present study attempts to evaluate Bhagat Puran Singh Sehat Bima Yojana in Punjab (BPSSBY).

METHODOLOGY This study is based on primary data collected through multi stage sampling. NFHS 4 revealed that in Punjab 22.2% households with any usual member are covered by the health insurance. Based on NFHS 4 two districts Rupnagar (Ropar) and Patiala have been selected owing to their highest and lowest proportion of health insurance coverage, respectively. Government of Punjab approved list of hospitals of both public and private hospital selected under BPSSBY is followed.

One public and one private hospital that provide healthcare to maximum beneficiaries under BPSSBY are identified in each of the two selected districts. These are Civil Hospital, Rupnagar and Gurdev Hospital, Nurpur Bedi from Rupnagar district and Mata Kaushlya Hospital, Patiala and Guru Nana Hospital, Rajpua from Patiala district. Randomly 25 beneficiaries, for the year 2017-18, from each identified hospitals are interviewed. In total the sample size comprise of 100 beneficiaries. The health official dealing with BPSSBY at the selected hospitals and district level and state level officials dealing with BPSSY are also interviewed.

FINDINGS STATUS OF BPSSBY IN PUNJAB Punjab government has undergone an agreement with United India Insurance Co. Ltd. Further United India Insurance Pvt. Ltd. has hired four private companies namely, M D India, Med Save, Safeway, and Vidal for technical support and named as third party administration (TPA). The department has framed more than 1000 packages to cover various health diseases under BPSSBY.

After the implementation of BPSSBY in Punjab since 2015, total 28.5 lakh households are enrolled under this scheme. These include households having blue card covered

6 under Atta Dal Scheme, J-form holders and labourers (www.bpssby.com). However the State Nodal Agency of BPSSBY Punjab has provided latest district wise distribution of 23.2 lakh households enrolled for BPSSBY up to the year 2018. This list is compiled by the state nodal agency BPSSBY Punjab on the basis of blue card holders only. Table 1 below reveals that 130068 and 74580 households are enrolled in district Patiala and Rupnagar which comprise approximately 9 percent of the total beneficiaries in Punjab.

Table 1: District wise Number of Households Enrolled for BPSSBY, 2018 District Enrolled Households Amritsar 169700 Barnala 59354 Bathinda 149046 Faridkot 62592 Fatehgarh Sahib 55351 Fazilka 115100 Ferozpur 77541 Gurdaspur 113307 Hoshiarpur 119889 Jalandhar 166321 Kapurthala 58317 Ludhiana 272425 Mansa 79406 Moga 83645 Mohali 71958 Mukatsar Sahib 114441 Pathankot 47104 Patiala 130068 Rupnagar 74580 S.B.S Nagar 56958 Sangrur 149580 Taran Tarn 97108 Total 23,23,791 Source: State Nodal Agency, BPSSBY, Punjab

Data on claims and amount disbursed for claims for the period November 2016 to July 2018 is also sought from the state nodal agency for BPSSBY in Punjab. It is found that during this period 103.9 Crore rupees are disbursed against 150674 claims in Punjab which is approximately on average Rs 6895.35 per claim. The average amount

7 disbursed during the above said period in Patiala and Rupnagar districts are Rs 6407.40 and Rs 6985.78 respectively. Average amount is maximum at Rs 9565.92 per claim in district Sri Muktsar Sahib and minimum at Rs. 4838.54 in Shahid Bhagat Singh Nagar district (Table 2).

Table 2: BPSSBY District wise Claims Status (November 2016 to July 2018) Total Claims District Average (Amount No. Amount (Rs) per claim) Amritsar 10710 68223813.5 6370.10 Barnala 6193 36921705 5961.84 Bathinda 10042 88148019 8777.93 Faridkot 9505 69068839 7266.58 Fatehgarh Sahib 5072 37768120 7446.40 Fazilka 4794 38533390 8037.84 Ferozepur 3180 19328877.5 6078.26 Gurdaspur 3706 24281115 6551.84 Hoshiarpur 4041 22841303 5652.39 Jalandhar 5525 38619036 6989.87 Kapurthala 1713 15451450 9020.11 Ludhiana 22687 132958130 5860.54 Mansa 7791 51434170 6601.74 Moga 2282 18657440 8175.92 Pathankot 1715 13631171 7948.20 Patiala 16024 102672211 6407.40 Rupnagar 11326 79120896 6985.78 Sahibzada Ajit Singh Nagar 6887 40768965 5919.70 Sangrur 6880 52587141 7643.48 Shahid Bhagat Singh Nagar 1909 9236775 4838.54 Sri Muktsar Sahib 6464 61834100 9565.92 Tarn Taran 2228 16869510 7571.59 Grand Total 150674 1038956177 6895.39 Source: State Nodal Agency, BPSSBY, Punjab

It is important to state the fact that the amount paid by the Punjab government as premium to the United India Insurance Pvt. Ltd. during the time period November 2016 to July 2018 is approximately Rs.161 croes which is much higher as compared to the claim amount disbursed. This clearly shows underutilisation of the scheme.

BACKGROUND CHARACTERISTICS OF BPSSBY CARD HOLDERS The 100 BPSSBY card holders interviewed during the survey register a family size of 4.6 with a total of 458 family members. The age of the card holder depicts its spread in almost all age groups with maximum in the age group of 41-60 years. Almost all BPSSBY card holders are above 31 years of age. It is interesting to interview 8 card holders from the younger lot of below 30 years age. More than half of the BPSSBY cards holders are in the age group of 41 to 60 years having 32 BPSSBY cards holders from district Patiala and 23 from district Rupnagar. Age of the 18 BPSSBY cards holders is above 60 years whereas 27 BPSSBY card holders reported their age below 40 years (Figure 1).

Figure 1: Age of the Beneficiaries

Patiala Rupnagar

15 14 12 12

7 7 8 4 1

Less than 30 31 -40 41 -50 51 -60 61 & Above

Gender, caste and marital status are also an important variable in the Indian social fabric. Two third BPSSBY cards holders are male and proportion of male to female BPSSBY card holders is approximately same in both districts. In terms of marital status, 89 BPSSBY card holders are married, 9 are widow/widower, one is divorced and another one is single in marital status. (Table 3)

Punjab, has the highest percentage of Scheduled Caste (SC) population (88.60 lakh) comprising 31.94 per cent of the total population of the State which is 4.3 per cent Scheduled Caste population of India. 73.33 per cent of the total SC population in Punjab by residence is predominantly rural. 61.4 per cent families below poverty line (BPL) in Punjab are SC families (Census of India, 2011). It is generally perceived that the social welfare schemes are largely meant for socially backward classes.

Caste wise data of the BPSSBY card holders in the present survey reveals that number of SC and Backward Class is quite high in Rupnagar district whereas in Patiala district majority of BPSSBY card holders belongs to general caste. However, the present study reveals that BPSSBY scheme has catered almost equally to different social groups (Table 3).

Table 3: Age, Gender, Marital Status and Caste Characteristics of the BPSSBY Card Holders Age Patiala Rupnagar Total Less than 30 7 1 8 31 -40 7 12 19 41 -50 20 15 35 51 -60 12 8 20 61 & Above 4 14 18 Total 50 50 100 Gender Male 32 35 67 Female 18 15 33 Total 50 50 100 Marital Status Married 47 42 89 Single 1 0 1 Divorced 0 1 1 Widow/Widower 2 7 9 Total 50 50 100 Caste General 22 9 31 Scheduled Caste 15 20 35 Backward Caste 13 21 34 Total 50 50 100

The level of education and occupation invariably has an influence on the level of awareness, extent of coverage, perception and expectation on various services and the quality of services delivered under any scheme. Educational level of respondents in the present study reveals that only one respondent is a graduate, 2 are senior secondary pass, 24 have done matriculation and 73 are either illiterate or middle pass or just have primary levels of education. The number of illiterate BPSSBY card holders is higher in Patiala district in comparison to Rupnagar district. The only graduate BPSSBY card holder is also from Rupnagar district. (Table 4)

Table 4: Educational and Occupational Status of the BPSSBY Card Holders Level of Education Patiala Rupnagar Total Illiterate 17 11 28 Primary 15 14 29 Middle 7 9 16 Matriculation 10 14 24 Senior Secondary 1 1 2 Graduate 0 1 1 Total 50 50 100 Occupation Unemployed 16 22 38 Agricultural Labourer 0 2 2 Farmer 4 6 10 Shop owner 3 5 8 Daily wager /labourer 22 15 37 Private service 5 0 5 Total 50 50 100

In terms of their occupation engagements, majority of the BPSSBY card holders (38) reported unemployed. Among them few are housewives and aged while others are not working due to their ill health. In addition, 37 BPSSBY card holders are labourers and daily wagers. Daily wage labouers are relatively more in Patiala district while unemployed are more in Rupnagar district. Ten BPSSBY card holders reported farming

11 as their source of livelihood followed by 8 as shop owners, 5 in private service and another 2 in agriculture labour (Table 4).

The total income of household is combined income of the household head and other family members who participate in any kind of economic activities. It represents the economic condition of the household. In the present study total income of household head and other family members living in same household has been inquired to understand the economic status of the family. Although respondents never reveal their actual income even than an estimate of their monthly income is probed. Figure 2 provides distribution of households across different income groups. 39 households reported that their monthly income from all sources ranges between Rs 5000 – Rs 9999 and 35 households reported that their monthly family income is between Rs 10000 – Rs 14999 per month. It is hard to survive with low income and to incur huge amount on health.

Figure 2: Family Income of the Card Holders

Patiala Rupnagar 23 19 16 16 12

6 5 2 1 0

less than 5000 5000 -9999 10000 -14999 15000 -19999 more than 20000

HOUSING CHARACTERISTICS OF BPSSBY CARDS HOLDERS Housing constitutes one of the most important indicators to judge the socio economic status of a person. Housing facilities gives complete information about the family and their earning levels. Access to basic amenities, such as proper housing, safe sanitation and safe cooking are the important measures to identify the socio–economic status of the household.

Almost all BPSSBY card holder households are residing in their own house. Only four BPSSBY households, two from each district are staying in rented accommodation. 82 BPSSBY card holder households have separate kitchen within their houses. 18 BPSSBY card holder households who do not have separate kitchen within house are either cooking their meals in courtyard or in the same room in which they are residing.

Table 5: Housing Characteristics of BPSSBY Card Holders House ownership Patiala Rupnagar Total Own 48 48 96 Rented 2 2 4 Total 50 50 100 Separate Kitchen within house Yes 42 40 82 No 8 10 18 Total 50 50 100 Toilet within the house Yes 46 42 88 No 4 8 12 Total 50 50 100 Alternate opted for Defecation Open Defecation 2 8 10 Share toilet with 2 0 2 Neighbour Total 4 8 12

On account of toilet facilities, 88 BPSSBY card holder households have toilet in their houses. Out of the twelve households who do not have toilet facility within their houses, 10 defecate in open and two of them use toilet facility in sharing with their neighbours. 8 out of 10 who defecate in open are from Rupnagar district. Despite the fact that department of sanitation, Punjab has declared these districts open defecation free districts, a sample of 100 household could identify 12 percent open defecation cases which is a cause of a concern (Table 5).

All BPSSBY card holder households have the electricity and tap water connection in their house premises which is much appreciated as these basic services can facilitate good health.

ENROLMENT IN BPSSBY Information from BPSSBY card holders is collected about the source of information for enrolment in BPSSBY, time taken for enrolment, years of enrolment, enrolment fee paid and documents submitted for enrolment.

Table 6 reveals that panchayat is the main source of information about the enrolment in scheme for majority (87) of BPSSBY card holders. Six household reported that local health staff informed them about the BPSSBY. Another three of them reported of their relative and neighbours as source of awareness on BPSSBY. Market committee officials and sales tax office personnel’s are also reported source of BPSSBY awareness by four respondents, two from each district.

Table 6: Source of information for enrolment in BPSSBY Source Patiala Rupnagar Total Relatives/neighbours 0 3 3 Health staff 5 1 6 Panchayat 42 45 87 Market committee Officials 1 1 2 Sales tax office Officials 1 1 2 Total 50 50 100

Attempt is also made to understand when the beneficiary was enrolled in BPSSBY. 18 out of 100 BPSSBY card holders reported that they are enrolled for more than four years now. Majority (62 card holders) are enrolled during the last 2 to 4 years period. 17 card holders are enrolled during the last one year time while 3 households are enrolled just few months before the survey. The enrolments under BPSSBY are thus seems to be a continuous process.

Table 7: Year of enrolment for BPSSBY and Time taken to get BPSSBY card Enrolled Before Patiala Rupnagar Total Less than one year 0 3 3 1-2 year 4 13 17 2-3 year 16 15 31 3-4 year 20 11 31 More than 4 years 10 8 18 Total 50 50 100 Time taken for the enrolment One day 1 5 6 One week 11 4 15 Two Week 5 4 9 One month 30 33 63 Two months 2 3 5 More than Two months 1 1 2 Total 50 50 100

70 out of 100 card holders could get their card after one or more months of submission of required documents followed by 9 card holders who could get their BPSSBY card within two weeks and another 15 card holders who could get their card within one week and yet another 6 respondents could get their card in one day after applying (Table 7).

The process seems to have simplified over these years and now the delivery of card to the beneficiary takes lesser time than before.

Card holders are asked if they had paid any amount for enrolment. 86 out 100 had paid nothing to get enrolled for BPSSBY. Among the 14 cardholders who paid for getting enrolled, majority of them paid Rupees 30 and one card holder reported to have paid Rupees 300 for enrolment. (Table 8)

Table 8: Enrolment Fee Paid for BPSSBY Paid for Enrolment Patiala Rupnagar Total Yes 6 8 14 No 44 42 86 Total 50 50 100 Amount paid for enrolment in BPSSBY (in Rs.) 30 4 8 12 50 1 0 1 300 1 0 1 Total 6 8 14

About nine out of every ten households have submitted documents related to their aadhar card and/or blue card meant for Atta Dal scheme. Four card holders reported to have submitted their sale tax number. Remaining card holders have submitted their ration card or voter card documents (Table 9).

Table 9: Documents Submitted for the Enrolment Process Documents Submitted Patiala Rupnagar Total Aadhar Card/ Blue Card 47 44 91 Ration Card 0 3 3 Voter Card 0 2 2 Sale tax number 3 1 4 Total 50 50 100

All households enrolled for BPSSY have received smart cards. With regard to the family members of 100 card holders enrolled under BPSSBY card, it s found that majority are enrolled. Out of the total 458 members of the 100 households surveyed. 408 are enrolled under BPSSBY. The 50 members of these households who are not enrolled for BPSSBY mainly include new born child and newly married daughter in laws. Thus, about 90 percent members of the household surveyed are covered under BPSSBY.

LEVEL OF AWARENESS The study has analysed awareness level about the benefits and various other components of the BPSSBY.

In terms of the level of awareness on the benefits under BPSSBY, only three-fourths of the sampled card holders (75 in number) are found fully aware. More number of respondents from Patiala district is found aware about all the benefits of the BPSSBY as compared to those from Rupnagar district (Table 10).

Table 10: Awareness about all the benefits of the BPSSBY Aware about all the benefits Patiala Rupnagar Total Yes 46 29 75 No 4 21 25 Total 50 50 100

Table 11 explains the level of awareness about the scheme among card holders corresponding to their education qualification, nature of occupation and caste. These include only those card holders who reported that they are aware about the benefits of BPSSBY. In general, we have a notion that awareness about the government schemes increases with the increase in the level of education. However, the study finds that illiterate card holders and those with education upto primary level are more aware on the benefits of BPSSBY.

Also, the study finds that the marginal population belonging to SC BPSSBY card holders are more aware about the benefits of BPSSBY scheme as compared to those in general category. In terms of awareness across nature of occupation, the study finds that 58 out of 75 BPSSBY card holders who are aware about the benefits of BPSSBY scheme are either unemployed or working as daily wage labourers. Thus the scheme seems to be well known amongst people with low level of education, downtrodden and poor and it can be said that that this scheme is serving well in their lives.

Table 11: Awareness about BPSSBY with respect to Educational Qualification, Caste and Occupation

Patiala Rupnagar Total Educational Qualification Illiterate 14 6 20 Primary 15 8 23 Middle 6 5 11 Matriculation 10 9 19 Sr. Sec. 1 1 2 Total 46 29 75 Caste Gen. 21 5 26 SC 13 15 28 BC 12 9 21 Total 46 29 75 Occupation Unemployed 13 17 30 Farmer 4 2 6 Shop owner 3 3 6 Daily wager /labourer 21 7 28 Private service 5 0 5 Total 46 29 75

The BPSSBY card holders are asked about the services that they ever availed specifically on the four main components of the scheme namely, cashless treatment, accidental insurance of the card holder, transport facility to the card holder and post hospitalization benefits to the household.

The BPSSBY card holders are if they know about any monetary benefits and cashless treatment that can be availed by a card holder. It is found that 65 out of 100 card holders knew that there are some monetary benefits available under the scheme. They are further asked to share their understanding on the amount that can be availed as benefits under this scheme. It is motivating to know that all 65 except one quoted the exact amount of Rs 50000/- that can be availed under this scheme. However, still 35 out of 100 did not know of monetary benefits of the scheme which is a matter of concern for the health department (Table 12).

Table 12: Awareness about monetary benefits available under BPSSBY Aware Patiala Rupnagar Total Yes 38 27 65 No 12 23 35 Total 50 50 100 How much (In Rs) 30000 0 1 1 50000 38 26 64

Cashless treatment is the major component of BPSSBY. Table 13 reveals that a good proportion of card holders (86 out of 100) are aware on cashless treatment facility under BPSSBY. However, lack of awareness on cashless treatment has been observed among 14 card holders. These are mostly from Rupnagar district. Again, the health department needs to intervene to spread complete awareness on the benefits that can be availed by the card holders.

Further, attempt is made to know card holder’s understanding on the nature of diseases that are covered under cashless treatment It is disheartening to know that 75 percent (65 out of 86) among those who reported awareness about the cashless treatment are not able to tell the disease that are covered for cashless treatment under BPSSBY. Rest 25 percent had idea only for the ailments for which they have availed the treatment (Table 13). Table 13: Awareness about the Cashless Treatment under BPSSBY Awareness about the Cashless Treatment Patiala Rupnagar Total Yes 49 37 86 No 1 13 14 Total 50 50 100 About which disease it is applicable Don’t Know 43 22 65 Only of ailments treated 7 14 21 Total 50 36 86

Another important component of BPSSBY are accidental insurance of Rs 5 lakh of the card holder, transport facility to card holder and post hospitalization benefits to the household covered under BPSSBY. It is disheartening to note a very poor response on account of awareness on these components. None except one card holder from Rupnagar district is aware on accidental insurance benefit under BPSSBY. Hardly three card holders could tell about the transport facility that is provided under BPSSBY. And, no card holder is aware about any post hospitalization benefits of BPSSBY (Table 14).

Table 14: Awareness on Major Components of BPSSBY Aware of accidental insurance benefit Patiala Rupnagar Total Yes 0 1 1 No 50 49 99 Total 50 50 100 Aware of any transport facility Yes 1 2 3 No 48 48 96 Total 50 50 100 Aware on post hospitalization benefits Yes 0 0 0 No 50 50 100 Total 50 50 100

BPSSBY provide a hospitalisation benefit of Rs 50,000 per year to the card holder household for any treatment. The hospitalisation expenses are deducted from their card after the discharge. The card holders are usually not told of the amount deducted from their card on discharge. Attempt is made to know the extent of this practice followed in the sampled hospitals. Beneficiaries were asked if they were made aware on the amount deducted by the hospital authorities on discharge. Big flaw is noticed on account of hospital staff that 81 beneficiaries were not apprised on the amount deducted from their card on discharge. One of them reported that he came to know the deducted amount after he received a SMS alert of value deduction on his registered mobile. Only 19 beneficiaries reported that they were told about the cost of treatment and that the cost will be deducted from the BPSSBY card (Table 15).

Table 15: Awareness on the amount deducted at discharge Aware Patiala Rupnagar Total Yes 4 15 19 No 46 35 81 Total 50 50 100

UTILIZATION OF BPSSBY Attempt is made to know the ailment for which the treatment is sought in the hospital by the beneficiary. A number of ailments are reported by the beneficiaries but majority of beneficiaries had availed treatment under BPSSBY for kidney diseases followed by urinary tract infection and uterus infection and gall bladder surgeries. Eight beneficiaries from Patiala district had availed BPSSBY for cataract surgery. The treatments availed under BPSSBY ranges from thyroid, dairioha, blood pressure, asthma, ENT, infections, fractures, blood infusion, and surgeries. Table 16: Ailments Treated under BPSSBY Ailments Patiala Rupnagar Total Cyst Uterus 0 3 3 ENT 1 4 5 Uterus/ UTI 8 9 17 Heart 0 1 1 Respiratory/ Asthma 0 3 3 Infection (Foot) 0 1 1 Blood pressure 2 4 6 Dubieties 0 1 1 Blood infusion 0 2 2 Spine Surgery 0 1 1 Fracture 0 3 3 Dairioha 2 3 5 Chest Infection 0 1 1 Infection 0 1 1 Gall Bladder Surgery 8 2 10 Kidney / Kidney Stone 10 9 19 Fits 1 0 1 Delivery 5 2 7 Blood Cancer 1 0 1 Cataract 8 0 8 Appendicitis 1 0 1 Hernia 2 0 2 Thyroid 1 0 1 Total 50 50 100

Information has been sought from beneficiaries that whether they have undergone for surgery as a part of treatment. It is interesting to find that more than half of the respondent card holders have availed BPSSBY for medical surgeries. Total 55 beneficiaries have availed surgery as treatment under BPSSBY and the proportion of beneficiaries is equal from both districts (Table 17).

Table 17: Scheme availed for Surgeries Availed Patiala Rupnagar Total Yes 28 27 55 No 22 23 45 Total 50 50 100

Further the data on surgery has been analysed to understand whether surgeries are performed at government or private hospitals. It is found that 29 surgeries are performed at government hospital and 26 surgeries are performed at private hospital (Table 18). In Rupnagar district, numbers of surgeries performed at private hospital are more than surgeries performed at government hospital while the situation is reversed in Patiala district. In district Patiala more surgeries are performed in government hospitals. One main reason mentioned by majority of them include that the health infrastructure and services are better at Mata Kaushlya hospital. It is also found that beneficiaries prefer to avail health services from their nearby health facilities. Majority of beneficiaries (92) interviewed have availed different health services from their respective districts.

Table 18: Preference for the Type of Hospital to avail BPSSBY for Surgeries Facility Number of Surgeries CH Rupnagar (Public hospital) 10 Gurudev Hospital Rupnagar (Private hospital) 17 Mata Kaushalya Hospital Patiala (Public hospital) 19 Guru Nanak hospital Patiala (Private hospital) 9

There are varying reasons to avail health services from different places either in their respective districts or other districts. The study reveals that it mainly depends on the

22 referrals. 57 beneficiaries reported that the main reason for choosing the place of treatment to avail health facilities was that they were referred to these facilities. 26 beneficiaries reported that they made their choice to avail the benefits of BPSSBY. Among them, 24 beneficiaries made their choice for treatment at private health facilities as without BPSSBY they can never afford to avail treatment from a private hospital (Table 19).

Table 19: Reasons for choosing health facilities for treatment Reasons Patiala Rupnagar Total Referred 26 31 57 Paternal Area 0 1 1 Nearby 9 4 13 Nearby to Relatives 1 1 2 For Scheme Benefits 14 12 26 Good facility 0 1 1 Total 50 50 100

Health facility wise distribution of reasons by patients availing treatment under BPSSBY clearly shows that the private health facilities are preferred by many to avail BPSSBY benefits (Table 20).

Table 20: Health Facility wise Distribution of Reasons for Choice of BPSSBY Beneficiaries on Place of Treatment Facilities Referred Paternal Nearby Nearby For Good Total Area to Scheme facility Relatives Benefits CH Rupnagar 20 1 2 1 1 0 25 Gurudev 11 0 2 0 11 1 25 Hospital Rupnagar Mata 21 0 2 1 1 0 25 Kaushalya Hospital Patiala Guru Nanak 5 0 7 0 13 0 25 hospital Patiala Total 57 1 13 2 26 1 100

Figure 3: All kind of medical treatment and tests are covered under BPSSBY: Beneficiaries Perception No 3%

Yes 97%

Figure 3 depicts perception of beneficiaries on the coverage of various kinds of medical treatment and medical tests under BPSSBY. The study finds that all beneficiaries except three reported that all medical tests and medical treatments are covered under BPSSBY. Table 21: Beneficiaries Experience on Out of Pocket Expenditure during Treatment Out of Pocket Expenditure Patiala Rupnagar Total Yes 15 16 31 No 35 34 69 Total 50 50 100 On What Medicines 14 13 27 Test 1 2 3 Hearing Aid 0 1 1 Amount Spent (in Rs) < 1000 2 2 4 1001 -2000 6 4 10 2001 -3000 4 1 5 3001 -5000 3 3 6 >5000 0 6 6 Total 15 16 31

However all find that the amount fixed under BPSSBY of Rs 50000/- per household is limited. Though 31 beneficiaries reported additional out of the pocket expenditure

24 during treatments, it is found that the aim of the scheme to eliminate or reduce out of the pocket expenditure is largely met but still to reach its finality. Majority of them (27) reported that a major part of out of pocket expenditure was on medicines. One beneficiary was found to purchase a hearing aid which is not covered under the scheme and hence had to bear the burden himself (Table 21).

It is found that ten beneficiaries have spent an additional amount between Rs 1000 to 2000 as out of the pocket expenses during the treatment and 12 beneficiaries reported to have spend additional amount of more than Rs 3000 as out of the pocket expenditure during the treatment.

SATISFACTION AMONG BENEFICIARIES All beneficiaries are satisfied with the kind of treatment they are able to avail under BPSSBY. All are thus satisfied with the scheme as a whole. None of them reported any difficulty in availing treatment either at the time of admission or discharge after treatment. It is satisfying to find that the health staff of health institutions do not discriminate with the beneficiaries of BPSSBY rather help them to avail full benefits of the scheme. People at large are very satisfied and feel delighted with the benefits of the scheme. The elderly are more satisfied and their statements favouring this scheme were very touching. Few such statements are mentioned below in verbatim:

“Sade gariban lai tan Rabb da vardan hai eh scheme. Mainu kidney di problem hai te mera dialysis hunda jekar scheme na hundi tan shayad main v na hunda .” (Beneficiary) He said that this scheme has been a blessing for him as he is suffering with kidney problem and is on dialysis which can be done only with the help of this scheme otherwise he could have never afforded and would have collapsed long back.

“Eh bahut wadia scheme hai, Meri nigah chali gayi c te mere kol paise nah hon karan main ilaj ni karwa pa riha c. Kuch lokan ne mainu mufat camp ch ilaj bare dasya par main kise haspatal ch ilaj karwauna chaunda c jo ke is scheme karan sambhav ho paya. Haspatal cho free operation kawaya te ajj main dekh sakda .” (Beneficiary) This beneficiary feels blessed to have availed eye operation under BPSSBY. According to him BPSSBY is a very good scheme. He never wanted to avail treatment from free eye

25 camps organised by unknown doctors. BPSSBY has made possible for him to get back his eye sight after getting his eyes operated for free from a good nearby hospital.

Such statements are meaningful and depict the need to strengthen such schemes or make the existing scheme more meaningful by covering all medical treatments to help people at large.

CONCLUDING REMARKS WITH RECOMMENDATIONS Community based health insurance schemes in India are predominantly aimed to bridge the gap between haves and haves not in availing health care services. These schemes are designed to relax the economic constraints faced by a huge section of society who are vulnerable in accessing and affording basic health care services. BPSSBY in Punjab is one such scheme which has shown remarkable results in terms of beneficiary’s satisfaction. However, the field observations and formal and informal interactions with various stakeholders of BPSSBY and local community members provided insights on various important aspects of the scheme.

1. Though it is expected to display the banner stating benefits under BPSSBY at proper place, either near the registration counter or at the hospital entrance, however, none of the four hospitals surveyed has displayed these banners at proper place. 2. Some beneficiaries were ignorant of any relevance of the BPSSBY card initially. For a long time they never used the card for availing any health care services out of ignorance. However, they started using the card after hearing about the benefits from some other patients. This implies carelessness and inadequate effort by the staff of concerned department to explain the card to the card holder on the day of enrollment which needs to be corrected to obtain effective results from the scheme. 3. It is expected that the hospital must apprise card holders the amount utilized for the treatment availed. However, this practice is largely not practiced by the hospitals. There has been a lacuna in not providing the beneficiaries with clarity on this. It is suggested that an SMS alert of amount deducted should be sent to the card holders.

4. State Nodal Agency of BPSSBY official mentioned case of denial of services by some empanelled private hospitals. The reasons may be many but must be related to administrative functioning of either the nodal agency or the hospitals. In such cases, patients should not be made to suffer. Sincere efforts from both public and private hospitals to accommodate BPSSBY card holders can make a big difference. Cases such as denial of services by the empanelled hospital should be sorted at the earliest. Complaints from the respondents regarding charging extra money for the treatment should be examined carefully and even beneficiaries should be properly counselled for the permissible provision of BPSSBY. 5. Delay in the claim payment is the major issue raised by the hospitals empanelled under the scheme. Such problems can be sorted by making staff at nodal agency accountable for pending works. However, problems related to innocence of beneficiaries, unable to understand the reasons associated with final increased cost of treatment due to reasons such as emergency to engage some specialist or anaesthetist does not call for any action against hospitals but at the same time, a counsellor at the complaint office can bring great difference in satisfaction levels amongst beneficiaries. 6. Another major problem reported by many include mismatch of particulars mainly ID proofs of card holder and family members submitted at the time of enrolling in the scheme and those submitted in the hospitals to avail BPSSBY. This creates problem at the time of claim settlement. When consulted with technical support team, it is found that the particulars of the household members of the card holder are uploaded as submitted by the card holder himself or are picked automatically from the lists of beneficiaries of Atta Dal Scheme. If any discrepancy already exists in uploaded lists it will be carried forward automatically as the system does not allow any changes. It is the responsibility of the card holder to enrol correct information or set it corrected by applying for desired changes. In such cases of discrepancies both beneficiaries and hospital face harassment. 7. The beneficiaries expect that enrollment under BPSSBY should be entitled for all inpatient and outpatient treatment, increased subsidies for medication and removal of caps on the various treatment modalities. This was endorsed by the

doctors and officials, who felt that there is underutilization of the scheme due to various restrictions. The absence of outpatient care is a big deterrent for effective results of BPSSBY. Also, the limited amount of Rs 50000/- is insufficient for many treatments and thus needs to be revised.

It is found that BPSBY has made visible impact in reducing the burden of health expenditure on the household income thereby making household income more effective resulting in better living of the beneficiaries of BPSSBY. A few adjustments related to inclusion of outpatient care, removing the cap on various treatment modalities and efficient complaint redress mechanism can harness full potential of BPSSBY. Lack of complete awareness on the benefits of BPSSBY at many levels needs to be addressed on regular basis. Information, education and communication department should be engaged to spread awareness on BPSSBY. Health officials should be made responsible to monitor the functioning and effectiveness of BPSSBY at all levels.

References Aggarwal Aradhna, 2010. Evaluating Innovation in Health Care Services: Impact of Yeshasvini Health Insurance Programme on Health Care Utilisation among Women. Health Economics 19(1): 5-35.

Agri Crisis: Punjab Saw 449 Farmer Suicides in 2015, 01 March 2016, HT, www.hindustantimes.com

Devadasan N, et al, 2011. Community health insurance schemes & patient satisfaction - evidence from India. Indian Journal of Medical Research 133: 40-49.

Dror David, et al, 2016. Impact of community-based health insurance in rural India on self-medication & financial protection of the insured. Indian Journal of Medical Research 143: 809-820.

International Institute for Population Sciences. 2015-16. National Family Health Survey 4: State and district fact sheet Punjab . New Delhi: Ministry of Health and Family Welfare, GOI.

Kuruvilla Sarosh and Liu Mingwei, 2007. Health Security for the Rural Poor? A Case Study of a Health Insurance Scheme for Rural Farmers and Peasants in India. International and Comparative Labor Relations Commons 60(4): 3-21.

Nagaraju Y, 2014. A Study on Performance of Health Insurance Schemes in India. International Journal of Innovative Research and Practices 2(4): 9-19.

Nandi Arindam, Holtzman E, Malani Anup and Laxminarayan Ramanan, 2015. The Need for Better Evidence to Evaluate the Health and Economic Benefits of “India’s Rashtriya Swasthya Bima Yojana”. Indian Journal of Medical Research 142 : 383-390.

Pandve, Harshal Tukaram. 2012. Health Insurance in Indian Context: Need of the Hour. Journal of Community Medicine Health and Education 2:9.

Prinja Shankar, et al, 2017. Impact of Publicly Financed Health Insurance Schemes on Healthcare Utilization and Financial Risk Protection in India: A Systematic Review. PLoS ONE 12(2): 1-19.

Rao Mala, et al, 2010. A Rapid Evaluation of Rajiv Aarogyasri Community Health Insurance Scheme in Andhra Pradesh, India. BMC Proceedings 6(1): 04.

Selvaraj Sakthivel and Karan Anup, 2012. Why Publicly-Financed Health Insurance Schemes Are Ineffective in Providing Financial Risk Protection. Economic and Political Weekly XLVII(11): 60-68.

Sinha Rajesh and Chatterjee Keya, 2014. Assessing Impact of India’s National Health Insurance Scheme (RSBY) : Is There Any Evidence of Increased Health Utilisation? International Journal of Humanities and Social Science 4(5): 223-232. www.bpbbsy.com www.censusindia.gov.in